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Quality and Governance

Good governance is the foundation of high quality, safe and effective healthcare. It ensures there is a clear framework of communication and accountability, effective systems and processes, measures and evidence to drive improvement, and a culture of honesty, integrity and openness.


Good Governance

At King Edward VII’s there is strong commitment to the structure, processes and culture of good governance, led by a highly effective and experienced governance team.  We support the hospital to provide the highest standards of quality care for patients in a safe, caring and professional environment.  There are many areas we oversee and manage within the hospital: patient safety, risk management, audit and compliance, credentialing, health and safety, infection control and prevention, complaints management, management of policies, guidelines and procedures, regulation and legal issues, performance and outcome indicators and information governance.

Find out more about the high-quality care you can expect in this Independent Healthcare Providers Network video:

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Patient Safety and Risk Management

The safety of patients in our care is paramount. We have the very best consultants, staff and facilities but all healthcare, like life, carries some risk so we minimise these in a number of ways. We have strong risk management systems that enable us to identify risks and issues and rectify them where able. We carry out regular audits, continually review and supervise housekeeping, the environment and catering services, encourage staff and patients to feedback on their experiences and have in depth reviews of our data to identify trends and issues.  We have an incident reporting system where errors, issues or near misses are reported to allow us to review, learn and improve when we have unexpected occurrences. Find out more about our Patient Safety Partner.

We have a culture of openness and transparency and will always protect the trusting relationship we have with our patients by keeping them informed about their care and treatment, but also if things don’t go to plan. We comply with statutory Duty of Candour but it is inherent in how we work here at the hospital.

The hospital has a comprehensive risk register where significant risks are logged and managed with Board level oversight. We also have external scrutiny with assessments and regulatory inspections.

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Infection Control and Prevention

We are proud of our zero incidence of MRSA blood stream infections or Clostridium Difficile. We have a reputation for cleanliness and infection control and will make every effort to minimise the risk of infection while patients are in our care.

Protecting You Against Infection

The hospital size enables us to closely monitor hygiene and infection control practices throughout the hospital. All ward patients have individual patient rooms with private en-suite which facilitates the potential of reducing infections.

Infection Control Team

Our hospital’s Infection Control Team, made up of a specially-trained, Master’s Degree educated senior nurse and skilled microbiologists, lead on screening patients for infection and also ensure the hospital follows strict guidelines around cleanliness.

In particular, we screen certain patients with risk factors and/or who are coming for certain procedures for MRSA prior to admission or on admission.

  • All staff receive ongoing training in hospital hygiene and infection control best practice.
  • Our in-house cleaning staff, available 24 hours a day, are trained by us to maintain a high standard of cleanliness. All rooms are cleaned daily and are deep-cleaned between occupancies.
  • Hand hygiene is essential for everyone in the hospital. We ask all patients and visitors to use the alcohol gel dispensers throughout the hospital to clean their hands.
  • Where possible we use single-use disposable equipment. In other circumstances equipment is cleaned, disinfected and sterilised in line with national protocols.
  • We fully comply with guidelines and protocols issued by the Department of Health and the National Institute for Health and Clinical Excellence for the prevention and control of infection.

MRSA Screening

MRSA (Methicillin-resistant Staphylococcus aureus) is relatively uncommon, but can be present on the skin or in the nasal passages of healthy people. If it is not strictly monitored, isolated and controlled it can cause complications, for example with wound healing.

We screen certain patients with risk factors and/or are coming in for certain procedures for MRSA at pre-assessment or on admission. This is a quick and painless procedure in which a nurse takes a sample from each nostril using a cotton bud. The sample is sent to the laboratory and if MRSA is detected we can treat the infection before complications occur.

The results are available within 24-48 hours and those whose test shows they have MRSA bacteria on the skin will be contacted and given an ointment for the nose and a body and hair wash to use for five days.

The MRSA swab result is valid for four weeks.

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Audit and compliance

The hospital has a continual audit programme in order to confirm that the best possible standards of care and service are consistently provided and, where there are any areas of improvement identified, act on these promptly. In addition we have an annual Patient Led Assessment of the Care Environment (PLACE) audit and in the last audit the results for Privacy, Dignity and Wellbeing fell above the national average.

We also submit data to the National Joint Registry, Public Health England, National Confidential Enquiry into Patient Outcome and Death,  the Private Healthcare Information Network and The Care Quality Commission.

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Patient experience and feedback

The hospital asks all patients to provide feedback on their experience. This feedback provides an invaluable opportunity for the hospital to know where care and services are doing well and where improvements are required.


The hospital receives very few formal complaints; we pride ourselves on being responsive to an individual’s needs at the time and quickly rectifying any issues. However, like all healthcare providers we do have a complaints process that ensures we listen to patients, undertake investigations to establish facts and information and provide feedback. We take the opportunity to learn from formal complaint feedback and make improvements where required. Simply email or download our complaints leaflet:

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Caldicott Guardian

The Caldicott Guardian advises on the ethical use of confidential information concerning staff and patients. King Edward VII’s Hospital’s Caldicott Guardian is Emmett Steed-Mundin (Director of Nursing).

If you wish to contact the Caldicott Guardian please email:

Policies, Guidelines and Standard Operating Procedures

All organisations need a clear system of documenting their position on topics relevant to their area of business, to guide clinical and professional decision making and to clearly describe approved practices. This is done through publishing policies, guidelines and standard operating procedures which, where available, reflect current best practice standards, up to date research evidence and relevant legislation.

King Edward VII’s Hospital has a considerable number of policy and guidance documents, aligned with National Institute of Clinical Excellence (NICE) and other national body best practice guidelines to ensure the highest quality of cutting edge care.

The policy and guidance documents also assist with education and training and ensure that all staff are working towards common aims and objectives. The Governance team has an overall role in supporting the development and review of all Hospital policies, guidelines and standard operating procedures the audit cycle and staffs ongoing learning.

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Concerns, comments and complaints

We are committed to ensuring that we deliver the highest standards of personalised patient-centred care in a safe and kind environment. Find out more about sharing concerns, comments and complaints.

Find out more